Pocket Emergency Paediatric Care - part 2 pot

Recognition of the sick child Early recognition and management of potential respiratory, circulatory, or central neurological failure will reduce mortality and secondary morbidity. The sections below describe the signs used for rapid assessment of children as part of the primary assessment: Airway Breathing Circulation Disability. Primary assessment of airway Vocalisations, such as crying or talking, indicate ventilation and some degree of airway patency. Assess patency by: looking for chest and/or abdominal movement listening for breath sounds feeling for expired air. Reassess after any airway opening manoeuvres In addition, note other signs which may suggest upper airway obstruction: the presence of stridor evidence of suprasternal recession (“tug”). Primary assessment of breathing Assess: Effort of breathing RECOGNITION OF THE SICK CHILD 17 Beware exceptions (fatigue, poisoning, neuromuscular diseases) Efficacy of breathing Effects of respiratory failure. Effort of breathing • Respiratory rate: tachypnoea – from either lung or airway disease or metabolic acidosis bradypnoea – due to fatigue, raised intracranial pressure, or pre-terminal. • Recession: intercostal, subcostal or sternal recession shows increased effort of breathing particularly seen in small infants with more compliant chest walls degree of recession indicates severity of respiratory difficulty in the child with exhaustion, chest movement and recession will decrease. • Inspiratory or expiratory noises: stridor, usually inspiratory, indicates laryngeal or tracheal obstruction wheeze, predominantly expiratory, indicates lower airway obstruction volume of noise is not an indicator of severity. • Grunting: seen in infants and children with stiff lungs to prevent airway collapse it is a sign of severe respiratory distress it may also occur in intracranial and intra-abdominal emergencies. • Accessory muscle use: in infants, the use of the sternomastoid muscle creates “head bobbing” and is ineffectual flaring of nasal alae. 18 POCKET EMERGENCY PAEDIATRIC CARE Exceptions Increased effort of breathing DOES NOT occur in three circumstances: exhaustion central respiratory depression, for example from raised intracranial pressure, poisoning, or encephalopathy neuromuscular disease, for example spinal muscular atrophy, muscular dystrophy or poliomyelitis. Efficacy of breathing • Breath sounds on auscultation: reduced or absent bronchial. • Symmetrical or asymmetrical chest expansion – (most important)/abdominal excursion. • Pulse oximetry. Normal SaO 2 in an infant or child at sea level is 95–100%. In air, this gives a good indication of the efficacy of breathing. SaO 2 at altitude may be lower. Effects of respiratory failure on other physiology • Heart rate: increased by hypoxia, fever, or stress bradycardia is a pre-terminal sign. • Skin colour: hypoxia first causes vasoconstriction and pallor (via catecholamine release) cyanosis is a late and pre-terminal sign some children with congenital heart disease may be permanently cyanosed and oxygen may have little effect. • Mental status: hypoxic or hypercapnic child will be agitated first, subsequently drowsy and then unconscious pulse oximetry may be difficult to achieve in the agitated child due to movement artefact. RECOGNITION OF THE SICK CHILD 19 Primary assessment of the circulation Assess: Circulatory status Effects of circulatory inadequacy on other organs Cardiac failure. Circulatory status • Heart rate. • Pulse volume: absent peripheral pulses or reduced central pulses indicate shock. • Capillary refill: pressure on the centre of the sternum or a digit for 5 seconds should be followed by return of the circulation in the skin within 2 seconds may be prolonged by shock or cold environmental temperatures neither a specific nor sensitive sign of shock should not be used alone as a guide to the response to treatment. • Blood pressure: cuff should be more than two thirds of the length of the upper arm and the bladder more than 40% of the arm’s circumference hypotension is a late and pre-terminal sign of circulatory failure expected systolic BP = 80 + (age in years × 2). (see Appendix, p 189) Effects of circulatory inadequacy on other organs/physiology • Respiratory system: tachypnoea and hyperventilation occurs with acidosis. • Skin: pale or mottled skin colour indicates poor perfusion. 20 POCKET EMERGENCY PAEDIATRIC CARE • Mental status: agitation, then drowsiness leading to unconsciousness. • Urinary output: < 1 ml/kg/h (< 2 ml/kg/h in infants) indicates inadequate renal perfusion. Features suggesting cardiac cause of circulatory inadequacy: cyanosis, not correcting with oxygen therapy tachycardia out of proportion to respiratory difficulty raised jugular venous pressure gallop rhythm/murmur enlarged liver absent femoral pulses. Primary assessment of disability Always assess and treat airway, breathing, and circulatory problems before undertaking the neurological assessment. Respiratory and circulatory failure will have central neurological effects. Central neurological conditions (for example, meningitis, raised intracranial pressure, status epilepticus) will have both respiratory and circulatory consequences. Neurological function Respiratory effects Circulatory effects Neurological function Conscious level – AVPU (a painful central stimulus may be applied by sternal pressure or by pulling frontal hair): Alert responsive to Voice responsive to Pain Unresponsive. • Posture: hypotonia decorticate or decerebrate postures (may only be elicited by a painful stimulus). opisthotonus for meningism or upper airway obstruction • Pupils: pupil size, reactivity and symmetry dilatation, unreactivity or inequality indicate serious brain disorders. Respiratory effects Raised intracranial pressure may induce: Hyperventilation Cheynes–Stokes breathing Slow, sighing respiration Apnoea. Circulatory effects Raised intracranial pressure may induce: Systemic hypertension Sinus bradycardia. RECOGNITION OF THE SICK CHILD 21 The shocked child Key features from a focused history • Diarrhoea, vomiting = fluid loss either externally (for example, gastroenteritis, especially infants) or into abdomen (for example, volvulus, intussuception, initial stage of gastroenteritis). • Fever and/or purpuric rash = septicaemia. • Urticaria, angioneurotic oedema, and allergen exposure = anaphylaxis. • Cyanosis unresponsive to oxygen with heart failure in a baby < 4 weeks = duct-dependent congenital heart disease. • Heart failure in an older infant or child = severe anaemia or cardiomyopathy. • Sickle cell disease, recent diarrhoeal illness, and very low haemoglobin = acute haemolysis. • An immediate history of major trauma points to blood loss and, more rarely, tension pneumothorax, haemothorax, cardiac tamponade, or spinal cord transection. • Severe tachycardia and abnormal rhythm on ECG = arrhythmia. • Polyuria, acidotic breathing, high blood glucose = diabetes. • Possible ingestion = poisoning. Specific examination of cardiovascular status Heart rate Tachycardia common. Bradycardia results from hypoxaemia and acidosis and is pre-terminal. THE SHOCKED CHILD 23 Pulse volume Poor pulse volume peripherally or, more worryingly, centrally. In early septic shock sometimes a high output state with bounding pulses. Capillary refill Slow capillary refill (> 2 seconds) after blanching pressure for 5 seconds on skin of the sternum. Mottling, pallor, and peripheral cyanosis also indicate poor skin perfusion. Difficult to interpret in patients exposed to cold. Blood pressure Blood pressure difficult to measure and interpret especially in young infants. Normal systolic BP = 80 + (2 × age in years). Hypotension is a late and often sudden sign of decompensation. Effects of circulatory inadequacy on other organs Acidotic sighing respirations. Agitation or depressed conscious level. Urinary output decreased or absent. A minimum flow of 1 ml/kg/h in children and 2 ml/kg/h in infants indicates adequate renal perfusion. Muscle tone: usually hypotonic. Treatment of shock ABC. Oxygen 100%, reservoir mask. IV cannula of widest bore (femoral, antecubital, or cut down or IO). Fluid resuscitation immediately – 20 ml/kg of crystalloid or colloid as fast as possible. Syringe into patient. Do not use dextrose solutions. Reassess and repeated boluses of 20 ml/kg if shock persists. 24 POCKET EMERGENCY PAEDIATRIC CARE Note: very large volumes of fluid resuscitation may be required early, especially in meningococcal infection and Dengue haemorrhagic fever. Use either 0·9% sodium chloride or colloid such as 4·5% human albumin. Blood products such as packed cells, fresh frozen plasma, and platelets may be required. • Patients who remain shocked after 40 ml/kg colloid/ crystalloid will probably benefit from inotropic support, for example dopamine 10–20 micrograms/kg/min IV (ideally central vein) or epinephrine 0·05–2·0 microgram/kg/min. • Shocked patients are at risk of pulmonary oedema as fluid therapy increases. Ideal therapy is mechanical ventilation with PEEP for patients receiving > 40 ml/kg fluids. If pulmonary oedema develops (for example, tachypnoea, hypoxia, cough and fine crackles, raised jugular venous pressure, and hepatomegaly) further fluid withheld until stable. Give inotropes. • Full neurological and cardiovascular assessment with regular (at least hourly) assessment of: pupillary responses, conscious level, pulse, blood pressure, capillary refill time, respiratory rate and effort (pulse oximetry if available), and temperature. • Regular (ideally 4 hourly initially) monitoring of electrolytes (sodium, potassium, calcium and magnesium, phosphate, urea and/or creatinine) and glucose and replacement of deficits. Blood gas. Severe metabolic acidosis (pH < 7·1), which does not respond to fluid therapy, and inotropes may require sodium bicarbonate correction. Regular blood gas monitoring essential for ventilated patients. • Monitor FBC and coagulation regularly if initially abnormal. Replacement of red cells to maintain Hb around 12 g/dL. Platelets and coagulation factors (usually FFP and cryoprecipitate) replaced as required to prevent bleeding. • Hydration usually IV but NG feeding if tolerated. Urine output monitored (by indwelling catheter if conscious level depressed). NG for gastric drainage if persistent vomiting or decreased conscious level. • If purpuric rash or other signs of septicaemia (after blood culture) IV antibiotic such as cefotaxime 50–100 mg/kg. • Fluids ideally warmed, but do not delay if not possible. Mother can place fluid bag next to her skin under dress to warm it. • 5 ml/kg 10% glucose IV (especially young child or infant) – after blood glucose test if available. • If bleeding or severe anaemia FBC, clotting, group and cross-match, give type-specific, non-cross-matched blood ABO and rhesus compatible (but has a higher incidence of transfusion reactions) (takes 15 minutes) if cannot wait 1 hour for full cross-match. In dire emergencies O rhesus negative uncross-matched. • If shock present and secondary to tachyarrhythmia: Identify rhythm, attach to ECG monitor, obtain 12 lead ECG if possible SSVVTT High flow oxygen Attempt vagal manoeuvres, establish IV/IO access No effect then use adenosine 50 micrograms/kg, then 100 micrograms/kg, then 250 micrograms/kg. Give as rapid boluses with rapid saline flush. If unsuccessful three synchronous electrical shocks at 0·5, 1·0 and 2 J/kg (following rapid sequence induction of anaesthesia if conscious) ((VVTT)) If arrythmia is broad complex, pulse is present but in shock use synchronous shocks at 0·5, 1·0 and 2 J/kg. (A conscious child must be anaesthetised or heavily sedated first) THE SHOCKED CHILD 25 [...]... (decerebrate) None to pain Eye Opening Verbal Motor 2 1 3 6 5 4 4 3 2 1 5 5 4 3 2 1 Score Adelaide Coma Scale (< 4 years) Best response Activity 30 POCKET EMERGENCY PAEDIATRIC CARE Respiratory pattern: • Irregular: consider seizures • Cheyne-Stokes: RICP cardiac failure , • Kussmaul: acidosis, central neurogenic hyperventilation, mid-brain injury, tumour, or stroke • Apneustic (periodic) breathing:... Treat RICP (see below for more details) • Mannitol (25 0–500 mg/kg; that is 1 25 2 5 ml/kg of 20 % IV over 15 minutes, and give 2 hourly as required, provided serum osmolality is not > 325 mOsm/L) • Dexamethasone (for oedema surrounding a space-occupying lesion: 500 micrograms/kg stat and then 50 micrograms/kg every 6 h) • Catheterisation for bladder care and urine output monitoring Intermediate • • •... Prevent child falling out of bed Nutritional support Skin care, prevent bed sores Eye padding to avoid xerophthalmia Chest physiotherapy to avoid hypostatic pneumonia Restrict fluids to 60% of maintenance if water retention Prevent deep vein thrombosis by physiotherapy  32 POCKET EMERGENCY PAEDIATRIC CARE • Maintain oral and dental hygiene • Appropriate care for central and peripheral venous or arterial access... and coordination where possible) Identify RICP (including herniation syndromes), focal deficits (for example, space occupying lesion (SOL)) and lateralising signs (hemiplegic syndromes) 28 POCKET EMERGENCY PAEDIATRIC CARE Further focused examination to identify cause Skin rashes: infections, for example meningococcal septicaemia, Dengue haemorrhagic fever Breath odour: diabetic ketoacidosis, alcohol... and extension — pre-terminal Decerebrate attacks — pre-terminal THE UNCONSCIOUS CHILD 33 • Irregular rate and rhythm of breathing, usually with slowing of respiratory rate – pre-terminal • Irregular heart rate, usually with bradycardia but occasionally with tachycardia, and mounting hypertension with widening pulse pressure – pre-terminal • Diminishing level of consciousness – pre-terminal The absence... Activity 2 1 3 6 5 4 5 4 3 2 1 4 3 2 1 Score Eyes open spontaneously To request To voice To pain None to pain Orientated, alert Recognisable and relevant words spontaneous cry Cries only to pain Moans only to pain None to pain Obeys commands Localises painful stimulus Withdraws from pain Abnormal flexion to pain (decorticate) Abnormal extension to pain (decerebrate) None to pain Eye Opening Verbal Motor 2. .. prevent temperatures > 37·5°C • Full neurological and cardiovascular assessment with regular (at least hourly) assessment of: pupillary responses, conscious level, pulse, blood pressure, 34 POCKET EMERGENCY PAEDIATRIC CARE capillary refill time, respiratory rate and effort (pulse oximetry if available) and temperature Maintain normoglycaemia and serum sodium (in high normal range > 135 mmol/L)/ osmolality... UNCONSCIOUS CHILD 31 Management Immediate (ABC) • Support respiration if necessary (support ventilation – maintain a PCO2 of 3·5–5·0 kPa) • Support circulation to maintain adequate cerebral perfusion (aim to keep systolic BP at normal values for age, avoid hypotension) • Maintain normo-glycaemia, if blood glucose not available give 5 ml/kg 10% glucose IV or NG • Maintain electrolyte balance (avoid hyponatraemia;... MEDICAL EMERGENCY • Assess ABC, give high flow oxygen (mask/reservoir 10–15 L/min), and obtain IV/intraosseous access • Treat shock (see above), if present, but exercise caution with fluid therapy DO NOT PERFORM LUMBAR PUNCTURE • Give mannitol 25 0 mg/kg to 500 mg/kg IV over 15 minutes (this should be repeated if signs of raised ICP persist) If mannitol is unavailable give frusemide 1 mg/kg IV If space-occupying... airway protection (if GCS < 8 and/or child is unresponsive to painful stimuli) and stabilisation of PCO2 • Mechanical ventilation with optimal sedation and maintenance of PCO2 within the normal range (ideally between 3·5 and 5 kPa) Other useful techniques include: • Placing patient supine with a 30° head-up position • Avoidance of central venous catheters in internal jugular veins • Antipyretics to prevent . pain (decerebrate) None to pain 5 4 3 2 1 5 4 3 2 1 6 5 4 3 2 1 30 POCKET EMERGENCY PAEDIATRIC CARE Respiratory pattern: • Irregular: consider seizures • Cheyne-Stokes: RICP, cardiac failure • Kussmaul:. 20 ml/kg of crystalloid or colloid as fast as possible. Syringe into patient. Do not use dextrose solutions. Reassess and repeated boluses of 20 ml/kg if shock persists. 24 POCKET EMERGENCY PAEDIATRIC. decorticate state (flexed arms, extended legs), rigidity, hypotonia, extension or flexion of contralateral limbs. 28 POCKET EMERGENCY PAEDIATRIC CARE Glasgow Coma Scale ( >> 4 years) Adelaide